Failure to Complete Post-Fall Assessments and Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate follow-up evaluations and condition assessments after a resident experienced a fall. Specifically, after a resident slipped and fell in their room, initial documentation indicated the resident was alert, denied hitting their head, and had no visible injuries. However, the following morning, red drainage was observed on the resident's right cheek and shirt, which the resident confirmed was related to the fall. Interviews with facility staff, including the DON and Administrator, confirmed that required neurological assessments, vital signs, and post-fall evaluations were not completed or documented as per facility policy, despite the fall being unwitnessed and resulting in an injury. Additionally, the facility did not follow physician's orders for the treatment of a foot ulcer for another resident. Review of the Treatment Administration Record (TAR) over several months revealed multiple instances where wound care treatments were not signed off as completed, and in some cases, treatments were marked as not done due to the resident sleeping, which was confirmed by the DON as not appropriate. The lack of documentation and completion of ordered treatments indicated that staff were not consistently following physician's orders for wound care.